Schnider and Eleveld Models for Propofol Target-Controlled Infusion Anesthesia: A Clinical Comparison.

BACKGROUND: Various pharmacokinetic/pharmacodynamic (PK/PD) models have been developed to accurately dose propofol administration during total intravenous anesthesia with target-controlled infusion (TIVA-TCI). We aim to clinically compare the performance of the Schnider model and the new and general-purpose Eleveld PK/PD model during TIVA-TCI. METHODS: We conducted a prospective observational study at a single center, enrolling 78 female patients, including 37 adults (aged < 65 years) and 41 elderly patients (aged ≥ 65 years). These patients underwent breast surgery with propofol-remifentanil TIVA-TCI guided by the bispectral index (BIS) for depth of anesthesia monitoring (target value 40-60) and the surgical plethysmographic index (SPI) for antinociception monitoring (target value 20-50) without neuromuscular blockade. The concentration at the effect site of propofol (CeP) at loss of responsiveness (LoR) during anesthesia maintenance (MA) and at return of responsiveness (RoR), the duration of surgery and anesthesia (min), the time to RoR (min), the propofol total dose (mg), the deepening of anesthesia events (DAEs), burst suppression events (BSEs), light anesthesia events (LAEs) and unwanted spontaneous responsiveness events (USREs) were considered to compare the two PK/PD models. RESULTS: Patients undergoing BIS-SPI-guided TIVA-TCI with the Eleveld PK/PD model showed a lower CeP at LoR (1.7 (1.36-2.25) vs. 3.60 (3.00-4.18) µg/mL, p < 0.001), higher CePMA (2.80 (2.55-3.40) vs. 2.30 (1.80-2.50) µg/mL, p < 0.001) and at RoR (1.48 (1.08-1.80) vs. 0.64 (0.55-0.81) µg/mL, p < 0.001) than with the Schnider PK/PD model. Anesthetic hysteresis was observed only in the Schnider PK/PD model group (p < 0.001). DAEs (69.2% vs. 30.8%, p = 0.001) and BSEs (28.2% vs. 5.1%, p = 0.013) were more frequent with the Eleveld PK/PD model than with the Schnider PK/PD model in the general patient population. DAEs (63.2% vs. 27.3%, p = 0.030) and BSEs (31.6% vs. 4.5%, p = 0.036) were more frequent with the Eleveld PK/PD model than with the Schnider PK/PD model in the elderly. CONCLUSIONS: The Schnider and Eleveld PK/PD models impact CePs differently. A greater incidence of DAEs and BSEs in the elderly suggests more attention is necessary in this group of patients undergoing BIS-SPI-guided TIVA-TCI with the Eleveld PK/PD than with the Schnider model.

Influence of Previous General Anesthesia on Cognitive Impairment: An Observational Study Among 151 Patients.

Introduction: Preoperative neurocognitive disorder (preO-NCD) is a common condition affecting 14-51. 7% of the elderly population. General anesthesia has already been associated with the one-year post-operative neurocognitive disorder (PostO-NCD), specifically, a deficit in executive function, measured by the Trail Making Test B (TMT-B), but its long-term effects on cognitive function have not been investigated. We aimed to detect preO-NCD prevalence in patients scheduled for cardiac surgery and further investigate the possible role of previous general anesthesia (pGA) in general preoperative cognitive status [measured via the Montreal Cognitive Assessment (MoCA)] and/or in executive functioning (measured via TMT-B). Methods: In this observational, prospective study, 151 adult patients scheduled for elective cardiac surgery underwent MoCA and TMT-B. Data on age, education, pGA, comorbidities, and laboratory results were collected. Results: We discovered a general cognitive function impairment of 79.5% and an executive function impairment of 22%. Aging is associated with an increased likelihood (OR 2.99, p = 0.047) and education with a decreased likelihood (OR 0.35, p = 0.0045) of general cognitive impairment, but only education was significantly associated with a decreased likelihood (OR 0.22, p = 0.021) of executive function impairment. While pGA did not significantly affect preO-NCD, a noteworthy interaction between aging and pGA was found, resulting in a synergistic effect, increasing the likelihood of executive function impairment (OR 9.740, p = 0.0174). Conclusion: We found a high prevalence of preO-NCD in patients scheduled for cardiac surgery. General cognitive function impairment is highly associated with advancing age (not pGA). However, older patients with at least one pGA appeared to be at an increased risk of preO-NCD, especially executive function impairment, suggesting that TMT-B should be associated with MoCA in the preoperative cognitive evaluation in this population.

[Cinema-based interventions implemented at the Day Hospital of Sapienza University of Rome - Policlinico Umberto I Hospital: group therapy, projective evaluation, psychoeducation and treatment] / Il cinema nella pratica psichiatrica: intervento di gruppo, test proiettivo, elemento di psicoeducazione, terapia. L'esperienza del Day Hospital del Policlinico Umberto I - Sapienza Università di Roma.

Cinema has been extensively used in psychiatric care. In the present article the cinema-based interventions implemented at the Day Hospital of Sapienza University of Rome - Policlinico Umberto I Hospital with various modalities and aims (e.g. rehabilitation, group therapies, projective evaluations, psychoeducation) will be discussed.

[Motivation in brief psychotherapy: a 30 patients study, valued in a psychiatric day-hospital]. / Motivazione al trattamento con psicoterapia breve: studio condotto su 30 casi valutati nel day hospital psichiatrico.

INTRODUCTION: The most important predictive factor for a successful outcome in Brief Psychotherapy is the motivation of patients to the treatment itself. Against the scarcity of literature on the subject, so far limited to offer standardized tools to assess motivation, applied mainly to education and work's areas, in spite of a possible application in psychotherapy, it was considered necessary to develop a questionnaire ad hoc. MATERIALS AND METHODS: It was therefore created a pattern of motivational diagnosis of the problem based on a sequence of questions and answers, which would make possible the classification of each case and then that could lead to the use of a specific method. It is the result of the attempt to create an orderly pattern and that it would be easy to use and then be analyzed. The questionnaire consists of twenty one questions and requires that the patient answers with a "yes" or a "no" to each applicant. It was administered to thirty patients who came from the psychiatric day hospital. The questionnaire was used as a "not standardized thread" in which, through groups of questions, are addressed some central cores: the spontaneous activity, motivation controlled from the outside, motivation directed to an activity that leads to results, motivation to and activity for a purpose, expectations of self-efficacy, the presence/absence of resistance and finally the area of the will. The purpose of this work is to show, bringing a contribution in agreement with the few studies on the subject, how motivation is a key parameter for predicting the effectiveness of a psychotherapy, in this case, Brief Psychotherapy. CONCLUSIONS: The study clearly shows how the motivation is the most important positive predictor in the preliminary assessment of a Brief Psychotherapy: results in treatment are most likely to be rapid and favorable if patients are motivated to change andif they are engaged with the therapist.